From the Guidelines
Elevated International Normalized Ratio (INR) treatment involves reversing anticoagulation, typically with vitamin K and/or fresh frozen plasma, to reduce the risk of bleeding.
Treatment Approach
- For patients with an INR > 4.5, the risk of major bleeding increases considerably, and reversal of anticoagulation is recommended 1.
- In patients with prosthetic valves who are not bleeding, intravenous vitamin K should not be used due to the risk of valve thrombosis if the INR falls rapidly 1.
- Oral vitamin K can be used in patients treated with long half-life vitamin K blockers, given in increments of 1 mg 1.
- If the INR is > 10.0, consideration should be given to the use of fresh frozen plasma 1.
- Reversal of anticoagulation should be more aggressive, using fresh frozen plasma and adapted doses of intravenous vitamin K, if there is active bleeding 1.
Specific Treatment Recommendations
- Prothrombin complex concentrate (PCC) and vitamin K can be used to reverse warfarin-induced coagulopathy, with PCC preferred due to its fast onset of action 1.
- In patients with acute intracranial hemorrhage (ICH) and an elevated INR, rapid reversal of anticoagulation is generally recommended, but the preferred method and consequences of this practice are unclear 1.
- The decision to restart anticoagulant therapy after ICH should be made on a case-by-case basis, considering the risk of recurrent hemorrhage and ischemic stroke 1.
General Principles
- The treatment approach should be individualized, taking into account the patient's underlying condition, risk factors, and the specific circumstances of the elevated INR.
- Close monitoring of the patient's INR and clinical status is essential to ensure safe and effective management of anticoagulation therapy.
From the Research
Treatment for Elevated International Normalized Ratio (INR)
The treatment for elevated INR depends on the severity of the elevation and the presence of bleeding.
- For patients with an elevated INR with mild or no bleeding, withholding warfarin and rechecking INR in 1 to 2 days is recommended. If INR >5, adding oral vitamin K supplementation is suggested 2.
- For major bleeding and elevated INR, hospital admission, vitamin K, fresh frozen plasma, and frequent monitoring are needed 2, 3.
- In emergent situations, hospitalization, clotting factor replacement, and vitamin K administered by slow intravenous infusion are required 2.
- For non-bleeding patients with an INR of 9, low-dose vitamin K1 (e.g., 2.5 mg phytonadione, by mouth) can be given 3.
- Plasma infusion can immediately drop the INR to 2.4 ± 0.9, and may be needed to reduce INR and the risk of bleeding within 24 hours, especially in hospitalized patients with INR higher than 9 4.
Special Considerations
- Patients with prolonged vomiting may require more frequent monitoring of INR due to decreased intake and retention of oral vitamin K-containing foods, which can lead to an elevated INR 5.
- Preemptive warfarin dose reduction may not be effective in preventing non-therapeutic INR, and may increase the likelihood of subtherapeutic INR compared to INR monitoring with reactive warfarin dose adjustment 6.